Safety of Acupuncture: Overview of Systematic Reviews

A review of the WHO strategy on traditional, complementary, and integrative medicine from the perspective of academic consortia for integrative medicine and health

Despite important progress in modern medicine, widely regarded as an indispensable foundation of healthcare in all highly advanced nations and regions, not all patients respond well to available treatments in biomedicine alone. Additionally, there are concerns about side effects of many medications and interventions, the unsustainable cost of healthcare and the low resolution of chronic non-communicable diseases and mental disorders whose incidence has risen in the last decades. Besides, the chronic stress and burnout of many healthcare professionals impairs the therapeutic relationship. These circumstances call for a change in the current paradigm and practices of biomedicine healthcare. Most of the world population (80%) uses some form of traditional, complementary, and integrative medicine (T&CM), usually alongside biomedicine. Patients seem equally satisfied with biomedicine and T&CM, but in the field of T&CM there are also many challenges, such as unsupported claims for safety and/or efficacy, contamination of herbal medicines and problems with regulation and quality standards. As biomedicine and T&CM seem to have different strengths and weaknesses, integration of both approaches may be beneficial. Indeed, WHO has repeatedly called upon member states to work on the integration of T&CM into healthcare systems. Integrative medicine (IM) is an approach that offers a paradigm for doing so. It combines the best of both worlds (biomedicine and T&CM), based on evidence for efficacy and safety, adopting a holistic personalized approach, focused on health. In the last decades academic health centers are increasingly supportive of IM, as evidenced by the foundation of national academic consortia for integrative medicine in Brazil (2017), the Netherlands (2018), and Germany (2024) besides the pioneering American consortium (1998). However, the integration process is slow and sometimes met with criticism and even hostility. The WHO T&CM strategies (2002-2005 and 2014-2023) have provided incipient guidance on the integration process, but several challenges are yet to be addressed. This policy review proposes several possible solutions, including the establishment of a global matrix of academic consortia for IM, to update and extend the WHO T&CM strategy, that is currently under review.

Participants experiences regarding the use of acupuncture as a treatment modality: A qualitative systematic review

BACKGROUND

Acupuncture is a promising modality in clinical practice, where the participants' experiences are crucial to acupuncture's use and effects. However, a comprehensive review synthesising participant experiences throughout treatment sessions is lacking. This study aims to explore the qualitative literature regarding participants' experiences of acupuncture as a potential treatment modality.

METHODS

A qualitative systematic review of existing literature was conducted through AMED, MEDLINE, Scopus, Embase, and Web of Science. The Joanna Briggs Institute (JBI) critical appraisal checklist was employed to evaluate research quality. Subsequently, the data were extracted and synthesised utilising the JBI Qualitative Assessment and Review Instrument (QARI) tool and data synthesis was carried out through meta-aggregation.

RESULTS

A total of twenty-eight articles were incorporated into the analysis. Four synthesised findings were identified: (1) Before acupuncture: last trust and hope; (2) During acupuncture: relaxing and calming; (3) After acupuncture: mind-body effects; and (4) Practitioner-participant relationship.

CONCLUSION

The findings highlight the changes participants experienced before and after acupuncture sessions. Implementing additional promotional initiatives for acupuncture can increase public awareness and encourage individuals to consider it an early symptom management option.

REVIEW REGISTRATION

This review was registered in PROSPERO (No. CRD42023475373).

Efficacy of acupuncture on cancer pain: A systematic review and meta-analysis

BACKGROUND

Pain associated with cancer is one of the greatest causes of reduced quality of life in patients. Acupuncture is one of the treatments used to address this issue, with the great advantage of having little or no side effects, especially when compared with pharmacological pain-killers.

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the current evidence regarding the efficacy of acupuncture for cancer pain.

SEARCH STRATEGY

Six electronic databases (PubMed, EBSCO, Cochrane Library, Scielo, b-On and Scopus) were searched for relevant articles about pain relief in cancer patients from their beginning until 2022 using MeSH terms such as "acupuncture," "electroacupuncture," "ear acupuncture," "acupuncture analgesia," ''oncological pain," and "cancer pain."

INCLUSION CRITERIA

Studies included were randomized controlled trials (RCTs) where acupuncture was compared with no treatment, placebo acupuncture or usual care.

DATA EXTRACTION AND ANALYSIS

Three independent reviewers participated in data extraction and evaluation of risk of bias, and a meta-analysis was conducted. The primary outcome was pain intensity, measured with the visual analog scale, numeric rating scale, or brief pain inventory. Secondary outcomes also assessed were quality of life, functionality, xerostomia, pain interference, and analgesic consumption. Results were expressed as standardized mean difference (SMD) with 95% confidence interval (CI).

RESULTS

Sixteen RCTs with a total of 1124 participants were included in the meta-analysis, with the majority of the studies presenting a low or unclear risk of bias. Acupuncture was more effective in reducing pain than no treatment (SMD = -0.90, 95 % CI [-1.68, -0.12]), sham acupuncture (SMD = -1.10, 95 % CI [-1.59, -0.61]) or usual care (SMD = -1.16, 95 % CI [-1.38, -0.93]).

CONCLUSION

The results of this study suggest that acupuncture may be an effective intervention to reduce pain associated with cancer. Despite some limitations due to the low quality and small sample size of some included studies, as well as the different types and stages of cancer, acupuncture might provide an effective and safe treatment to reduce cancer pain. Please cite this article as: Faria M, Teixeira M, Pinto MJ, Sargento P. Efficacy of acupuncture on cancer pain: A systematic review and meta-analysis. J Integr Med. 2024; 22(3): 235-244.

The reporting quality of acupuncture-related traumatic adverse events: a systematic review of case studies in Korea

BACKGROUND

Acupuncture is known for a harmless treatment when administered by well-trained clinicians. However, multiple case reports of traumatic adverse events (AEs) related to acupuncture treatments continue to be published in literature. In this review, we evaluated the reporting quality and conducted causality assessments of case studies that have reported acupuncture-related traumatic AEs in Korea.

METHODS

Eight databases were searched from their inception to January 2024. Only Korean case studies that reported traumatic AEs following acupuncture procedures were included without any language restrictions. Reporting quality was evaluated based on patient characteristics, AEs, and acupuncture practice. Causality was assessed using the modified WHO-UMC causality criteria.

RESULTS

Twenty-eight studies were included from a total of 1,154 identified studies. The quality of reporting in the included studies was low overall. While the descriptions of patient characteristics and AEs were relatively well detailed, most information on acupuncture practice was not reported at all. During the causality assessment, only three (10.7%) studies were judged to be "certain". Twelve (42.9%) studies were "unassessable" because they inadequately described the information necessary for decision-making. It was practically difficult to establish the causality between acupuncture and AEs, as well as the appropriateness of acupuncture practice.

CONCLUSIONS

Insufficient and inappropriate reporting was observed in most case studies reporting acupuncture-related traumatic AEs in Korea. To overcome these limitations, we have suggested tentative guidelines in the form of a set of items that should be reported by future authors who plan to publish case studies on acupuncture-related traumatic AEs in a clinical setting.

Acupuncture as a Complementary Treatment Modality in the Post-Anesthesia Care Setting: A Feasibility Study

Introduction: Postoperative pain management and postoperative nausea and vomiting are a persistent challenge for both health care providers and patients. Acupuncture is an effective and safe modality for the management of pain and nausea, and has the potential to play a key role in postoperative pain management. This study explores the utility and feasibility of acupuncture in the immediate postoperative setting. Methods: In a retrospective case-control study, 22 patients who underwent elective surgeries and received acupuncture in the post-anesthesia care unit (PACU) were compared with 88 case controls. Indications for acupuncture therapy included persistent pain, nausea, or anxiety. Patient satisfaction and symptom improvement after acupuncture were assessed. PACU nurses and patients were queried on their perspectives on using this therapy. Demographic data, perioperative opioid consumption, pain score in the PACU, incidence of postoperative nausea, PACU length of stay, and unintended hospital admission were assessed. The groups with/without acupuncture were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate. Results: A total of 78.9% of patients receiving acupuncture felt improvement in their symptoms. 94.7% of recovery nurses who cared for patients who received acupuncture felt that it was helpful and 78.9% did not believe it was disruptive. Patients who opted for acupuncture had a statistically significant higher overall median (interquartile range) pain score in the PACU (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0], p = 0. 03). There was no difference between total perioperative opioid consumption between groups (p = 0.94). Conclusions: Most patients who received acupuncture therapy in the PACU were satisfied with their therapy and would recommend it to future patients undergoing surgery. Most recovery nurses felt it was helpful, was not disruptive, and would like to see it utilized in the PACU.

Effects of acupuncture or similar needling therapy on pain, proprioception, balance, and self-reported function in individuals with chronic ankle instability: A systematic review and meta-analysis

OBJECTIVE

Acupuncture or similar needling therapy has long been used to improve well-being, but its effectiveness in management of chronic ankle instability (CAI) is unclear. To investigate the efficacy of acupuncture or similar needling therapy on pain, proprioception, balance, and self-reported function in individuals with CAI.

METHODS

Nine databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, WanFang, and CQVIP) were systematically searched from inception to April 2023. This study included randomized controlled trials involving acupuncture or similar needling therapy as an intervention for individuals with CAI. Data were extracted independently by two assessors using a standardized form. Literature quality and risk bias were assessed by using the PEDro scale.

RESULTS

Twelve trials (n = 571) were found, of which the final meta-analysis was conducted with eight. Different studies employ varying treatments, including specific needle types, techniques, and therapeutic frameworks. Compared to control without acupuncture or similar needling therapy, acupuncture or similar needling intervention resulted in improved pain (WMD 1.33, 95 % CI 0.14-2.52, I²=90 %, p = 0.03), proprioception (active joint position sense, WMD 1.71, 95 % CI 0.95-2.48, I²=0 %, p < 0.0001), balance (SMD 0.54, 95 % CI 0.03-1.04, I²=46 %, p = 0.04), and self-reported function (Cumberland Ankle Instability Tool (WMD 2.92, 95 % CI 0.94-4.90, I²=78 %, p = 0.004); American Orthopedic Foot and Ankle Society (WMD 9.36, 95 % CI 6.57-12.15, I²=0 %, p < 0.001); Foot and Ankle Ability Measure: activities of daily living (WMD 5.09, 95 % CI 1.74-8.44, I²=0 %, p = 0.003)) for individuals with CAI.

CONCLUSIONS

The available evidence suggests that acupuncture or similar needling therapy may improve pain, proprioception, balance, and self-reported function in individuals with CAI, but more trials are needed to verify these findings. Furthermore, various needles and techniques using in different studies have resulted in methodologic limitations that should be addressed in the future.

Effective Treatment of Knee Osteoarthritis Using a Nano-Enabled Drug Acupuncture Technology in Mice

A nano-enabled drug delivery acupuncture technology (nd-Acu) is developed that is based on traditional acupuncture needles where the stainless-steel surface is designed to deliver various payload molecules. To create the nd-Acu platform, an electrochemistry procedure is used to attach methyl salicylate-modified cyclodextrin in which the sugar rings allow the encapsulation of structurally defined single or multiple payload molecules via an inclusion complexation process. Drug loading and release profile are first studied using fluorescent dyes abiotically and at intact animal level. nd-Acu allows more efficient dye loading and time-dependent release compared to pristine needles without cyclodextrin modification. Subsequently, a proof-of-principle efficacy study is conducted using the platform to load a local anesthetic, lidocaine, for the treatment of knee osteoarthritis (KOA) in mice. It is demonstrated that lidocaine-laden nd-Acu can effectively alleviate pain, reduce inflammation, and slow down KOA development biochemically and histologically. Hypothesis-driven and proteomic approaches are utilized to investigate the working mechanisms of lidocaine nd-Acu, indicating that the therapeutic outcome is attributed to the in vivo modulation of the HMGB1/TLR4 signaling pathway. The study also obtained preliminary evidence suggesting the involvement of mitochondria as well as small GTPase such as cdc42 during the treatment by lidocaine nd-Acu.

Multimodal Care of a Patient With Functional Movement Disorders Following a Motor Vehicle Accident: A Case Report

Objective

The purpose of this case report was to describe the multimodal care of a patient with the sudden onset of truncal tremors.

Clinical Features

A 30-year-old female patient presented for chiropractic care with truncal tremors following a motor vehicle accident. Initial outcome measures included the Neck Disability Index (50%) and Oswestry Disability Index (62). The patient's truncal tremors became worse during spinal cord compression testing that included passive cervical flexion and slouched posture. The Romberg test was positive for swaying. Assessments of active range of motions of the cervical, thoracic, and lumbar spine were moderately reduced in all ranges. Case history, physical examinations, diagnostic imaging, and neurology consultations led to a diagnosis of functional truncal tremors. The patient was being concurrently managed by other health care providers. Magnetic resonance imaging studies were ordered by a neurologist and primary medical physician, which showed no structural abnormalities in brain neuroanatomy or spine.

Intervention and Outcome

The multimodal chiropractic care included whole-body vibration therapy (WBVT), spinal manipulative therapy (SMT), and acupuncture therapy. The treatment plan included 8 weekly appointments in which the patient received WBVT and SMT. During treatment weeks 2 to 6, the patient received acupuncture therapy, which occurred immediately following their treatment appointment for WBVT and SMT. The patient practiced stress reduction techniques, as advised by the neurologist, eliminated caffeine, and performed daily yoga exercises for 30 minutes. The Romberg test was negative after the third treatment. The patient was discharged after chiropractic visit 12, 95 days post-accident, as she reached maximal medical improvement. Truncal tremors were still present, but the patient described them as "barely noticeable."

Conclusion

The patient reported improvement under a course of chiropractic care using a multimodal approach, including behavioral, pharmacological, and manual therapies. This case study suggests that WBVT, SMT, and acupuncture therapy may assist some patients with functional movement disorders.

Is acupuncture safe in the ICU? A systematic review and meta-analysis

Background and purpose

The safety of interventions for critically ill patients is a crucial issue. In recent years, several studies have treated critically ill patients with acupuncture. However, the safety of acupuncture in this setting remains to be systematically measured.

Methods

In May 2022, the electronic databases of PubMed and the Cochrane Library were searched for studies comparing acupuncture interventions to control interventions in critically ill patients. Study outcomes examined the incidence of severe adverse events (AEs), minor AEs, adverse reactions, ICU stays, and 28-day mortality.

Results

A total of 31 articles were analyzed, and no serious AEs related to acupuncture treatment were identified. No significant differences were found between the groups in the meta-analysis of minor AEs (risk ratio [RR] 5.69 [0.34, 96.60], P = 0.23, I2 = 76%). A reduced risk in the incidence of adverse reactions following acupuncture intervention was evidenced (RR 0.33 [0.22, 0.50], P = 0.00001, I2 = 44%). The patients in the acupuncture arm spent significantly less time in the intensive care unit (ICU) (Mean difference -1.45 [-11.94, -10.97], P = 0.00001, I2 = 56%) and also exhibited lower 28-day mortality rates (odds ratio 0.61 [0.48, 0.78], P = 0.0001, I2 = 0%).

Conclusion

There is no evidence to indicate a higher risk of severe or minor AEs in patients who receive acupuncture. Acupuncture demonstrated favorable results in both ICU stay and 28-day mortality measurements, in addition to presenting with fewer adverse reactions compared to routine ICU care. However, the low certainty of the evidence resulting from a high risk of bias in the included studies merits substantial consideration, and further research is still warranted.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=142131, identifier: CRD42020142131.

The Role of Self-Care Acupressure in Maternal Health Problems to Support the Sustainable Development Goals Program in the Health Sector: A Narrative Review

Objective

This narrative review discusses several studies that demonstrated the effect of self-care acupressure, especially on maternal-health problems in antenatal, labor, and postpartum times, as well as the mechanism of acupressure, the points used, and treatment strategies to support the Sustainable Development Goals (SDGs) program in the health sector.

Methods

PubMed and Google Scholar were searched for randomized controlled trials and systematic reviews/meta-analyses from the date of their inception to February 2022.

Results

The 14 studies that were included showed the possibility that acupressure could have a positive impact on maternal health. This self-care can be the main alternative in overcoming the gap in solving health problems in the world.

Conclusions

Self-care acupressure at various acupoints has been shown to be feasible to reduce problems during antenatal, labor, and postpartum times. Additional research on the use of acupressure during pregnancy and cross-sectional collaboration to increase the awareness of acupressure techniques are needed.

Acupuncture and related therapies for tension-type headache: a systematic review and network meta-analysis

Background

Tension-type headache (TTH) is one of the most common primary headaches. Several studies have confirmed the efficacy of acupuncture therapies for TTH, but it is uncertain which treatment is most effective.

Objective

This study aimed to compare the effectiveness and safety of different acupuncture therapies for TTH using Bayesian Network Meta-analysis to provide new ideas for treating TTH.

Methods

Nine databases were searched for randomized controlled trials (RCTs) about different acupuncture therapies for TTH up to December 1, 2022. The outcome indicators analyzed in our study were total effective rate, visual analog scale (VAS), headache frequency, and safety. Pairwise meta-analysis and risk of bias assessment were performed using Review Manager 5.4. Stata 15.0 generated a network evidence plot and detected publication bias. Finally, a Bayesian network meta-analysis of the data was used by RStudio.

Results

The screening process resulted in 30 RCTs that met the inclusion criteria, including 2,722 patients. Most studies failed to report details of trials and were therefore assessed as unclear risks. Two studies were considered high risk because they did not report on all pre-specified outcome indicators or had incomplete data on outcome indicators. The NMA results showed that for total effective rate, bloodletting therapy had the most considerable SUCRA value (0.93156136), for VAS, head acupuncture combined with Western medicine ranked first (SUCRA = 0.89523571), and acupuncture combined with herbal medicine was the most effective in improving headache frequency (p > 0.05).

Conclusion

Acupuncture can be used as one of the complementary or alternative therapies for TTH; bloodletting therapy better improves the overall symptoms of TTH, head acupuncture combined with Western medicine is more effective in reducing VAS scores, and acupuncture combined with herbal medicine seems to reduce headache frequency, but the difference is not statistically significant. Overall, acupuncture for TTH is effective with mild side effects, but future high-quality studies are still necessary.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, PROSPERO [CRD42022368749].

Sedative-sparing effect of acupuncture in gastrointestinal endoscopy: systematic review and meta-analysis

Objective

This study aimed to perform a systematic review and meta-analysis to identify the efficacy of acupuncture therapy (including manual acupuncture and electroacupuncture) performed before or during gastrointestinal endoscopy with propofol as the main sedative, compared with placebo, sham acupuncture, or no additional treatment other than the same sedation.

Methods

A systematic search was performed through PubMed, Embase, Web of Science, Cochrane Library, Chinese Biomedical Databases (CBM), Wanfang database, China National Knowledge Infrastructure (CNKI), SinoMed, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials published before 5 November 2022. Bias assessment of the included RCTs was performed according to Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). Stata16.0 software was used to perform statistical analysis, sensitivity analysis, and publication bias analysis. The primary outcome was sedative consumption, and the secondary outcomes included the incidence of adverse events and wake-up time.

Results

A total of 10 studies with 1331 participants were included. The results showed that sedative consumption [mean difference (MD) = -29.32, 95% CI (-36.13, -22.50), P < 0.001], wake-up time [MD = -3.87, 95% CI (-5.43, -2.31), P < 0.001] and the incidence of adverse events including hypotension, nausea and vomiting, and coughing (P < 0.05) were significantly lower in the intervention group than in the control group.

Conclusion

Acupuncture combined with sedation reduces sedative consumption and wake-up time compared with sedation alone in gastrointestinal endoscopy; this combined approach allows patients to regain consciousness more quickly after examination and lower the risk of adverse effects. However, with the limited quantity and quality of relevant clinical studies, caution must be applied until more high-quality clinical studies verify and refine the conclusions.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier: CRD42022370422.

Effects of acupuncture on earthquake survivors with major psychiatric disorders and related symptoms: A scoping review of clinical studies

BACKGROUND

This scoping review aimed to determine the current research status of acupuncture for major psychiatric disorder (MPD) in earthquake survivors.

METHOD

We followed the scoping review process described previously. A literature search on 14 electronic databases was conducted from inception to November 29, 2022. Data from the included studies were collected and descriptively analyzed to address our research question. Extracted data were collated, synthesized, and summarized the according to the analytical framework of a scoping review.

RESULT

This scoping review included nine clinical studies: four randomized controlled trials (RCTs) and five before-after studies. The most frequent MPD type among the included acupuncture studies was posttraumatic stress disorder (PTSD; 6/9, 66.67%). The most frequent acupuncture type was scalp electro-acupuncture (4/9, 44.44%), followed by manual acupuncture and ear acupressure/ear acupuncture (3/9, 33.33%). Studies using scalp electro-acupuncture all used common acupoints, including GB20, GV20, GV24, and EX-HN1. In general, the treatment period lasted between 4 and 12 weeks. Validated assessment tools for PTSD severity and accompanying symptoms were used for patients with PTSD, while the corresponding evaluation tools were used for patients with other diagnoses or clinical symptoms. Acupuncture-related adverse events were generally mild and temporary, such as mild bleeding and hematoma, and syncope was a rare but potentially serious adverse event (1/48 patients and 1/864 sessions over a treatment period of 4 weeks).

CONCLUSION

Acupuncture studies for MPD after an earthquake mainly focused on PTSD. RCTs accounted for around half of the included studies. Scalp electro-acupuncture was the most common acupuncture type, and EX-HN1 and GV24 were the most important acupoints in the acupuncture procedures for MPD. The included studies mostly used validated symptom assessment tools, though some did not. Clinical studies in this field need to be further expanded regardless of the study type.

PROTOCOL REGISTRATION

https://osf.io/wfru7/.

Effect of Acupoint Stimulation on Controlling Pain from Heel Lance in Neonates: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To evaluate the effect of acupoint stimulation compared to other interventions on pain control in neonates who underwent heel lance, we searched for randomized controlled trials across six databases (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, and Web of Science) published up to January 2023. Studies comparing acupoint stimulation and other interventions for controlling heel lance pain in neonates were included. These reports measured at least one of the following variables: pain score, crying time, oxygenation saturation, heart rate, respiration rate, and duration of the procedure. The data were independently extracted by two authors, and the PRISMA guidelines for study selection were followed. A total of 79 articles were screened, and 10 studies, with results on 813 neonates, were included in the final selection. The pain scores recorded during the heel lance procedure were not significantly different between the acupoint stimulation cohort and the control cohort (SMD of -0.26, 95% confidence interval (CI) from -0.52 to 0.01; p = 0.06; I² = 68%). After processing the subgroup analyses, significant differences were found in the comparisons of acupuncture vs. usual care (SMD of -1.25, 95% CI from -2.23 to 0.27) and acupressure vs. usual care (SMD of -0.62, 95% CI from -0.96 to -0.28); nonsignificant differences were found in other comparisons. Our results demonstrate that acupoint stimulation may improve pain score during the heel lance procedure.

Complementary and integrative medicines for behavioral and psychological symptoms of dementia: Overview of systematic reviews

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSDs) are major contributing factors to disease burden in dementia patients. Complementary and integrative medicine (CIM) has received attention in the management of dementia in patients with BPSDs. This overview aimed to comprehensively and critically review previous systematic reviews (SRs) of CIM modalities for BPSD management.

METHODS

Thirteen databases were searched in November 2021 to identify SRs on CIM for BPSDs. The methodological quality of the included studies was assessed using A MeaSurement Tool to Assess systematic Reviews 2.

RESULTS

Among 38 SRs, aromatherapy was the most commonly studied intervention, followed by herbal medicine (HM), acupuncture/acupressure, mindfulness-based interventions, relaxation, and Taichi. Half of the studies on aromatherapy reported significantly improved BPSDs, especially agitation, while the remainder reported mixed results/insufficient evidence. Most studies (85.71%) on HM supported its significant benefits in BPSDs. Yokukansan, an individual HM, was most frequently studied for BPSDs, with a significant beneficial effect on delusions, hallucinations, and agitation/aggression. Moreover, some meta-analyses supported the benefits of HM as an adjunct to psychotropic drugs in BPSD management. Other CIM interventions had insufficient clinical evidence. The methodological quality of the included studies was poor, and most were rated low or critically low (92.11%).

CONCLUSION

Aromatherapy, the most frequently investigated CIM for BPSD, had mixed results or insufficient evidence. HM, as an adjunct to psychotropic drugs including antipsychotics, exhibited additional benefits regarding the efficacy and safety for BPSDs. This overview emphasizes the requirement for greater quantity and quality of research in this field.

REGISTRATION NUMBER

Open Science Framework registry (g5f3m) (https://osf.io/g5f3m), PROSPERO (CRD42020211009) (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020211009).

Effect of acupuncture in myelosuppression and quality of life in women with breast cancer undergoing chemotherapy: a randomized clinical study

OBJECTIVE

This study aimed to evaluate the effect of acupuncture on myelosuppression and quality of life in women with breast cancer during treatment with anthracyclines (ANT).

METHODS

Women with indication for ANT chemotherapy were randomized into two groups: acupuncture group (AG) and control group (CG). A quality of life questionnaire (FACT-G) and peripheral blood levels of the participants were evaluated before and at the end of treatment. The AG was submitted to an acupuncture intervention, starting before the first chemotherapy infusion, and continuing throughout the treatment.

RESULTS

A total of 26 women were randomized into 2 groups: AG (10) and CG (16). Of these, 26.9% had a dense dose indication according to the service's protocol for the administration of granulocyte-stimulating factor (G-CSF) from the first cycle, not participating in the analysis. The need for secondary prophylaxis with G-CSF occurred in 72.7% in the control group versus 12% in the acupuncture group. Regarding quality of life (QoL), it was observed that the groups did not initially differ from each other. At the end of the treatment, there was a significant difference in the AG for the physical (GP) (p-value=0.011), social/family (GS) (p-value=0.018), and functional (GF) (p-value=0.010) domains, regarding the initial and final FACT-G showed a difference between the groups, where the GA average at the end rose from 80.68 to 90.12 (p-value = 0.004) and in the CG the average dropped from 81.95 to 70.59 (p-value=0.003).

CONCLUSION

Acupuncture was efficient in the secondary prophylaxis of myelosuppression during chemotherapy and the quality of life of women during treatment has increased.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials - Rebec on 06/28/2018, registration number U1111-1216-3921, Rebec Trial RBR-7BWJ6R.

Effects of acupuncture on the miR-146a-mediated IRAK1/TRAF6/NF-κB signaling pathway in rats with sarcopenia induced by D-galactose

Background

Sarcopenia during aging is closely linked to sterile, low-grade, chronic inflammation. However, considering the increasingly aging global population, the effectiveness of existing treatments for sarcopenia is not exact, and acupuncture, as an effective anti-inflammatory therapy, has the potential to treat it.

Methods

Fifty Sprague-Dawley rats were randomly allocated into five groups, including Control group, D-galactose (D-gal) group, D-gal + acupuncture (DA) group, D-gal + non-acupoint (DN) group and D-gal amino acid mixture (DAA) group. An aging rat was model constructed using D-gal for 12 weeks. Rats in the control group received 0.9% physiological saline daily. Treatment groups were acupunctured or given amino acid mixture interventions daily, and lasted for last 4 consecutive weeks. The effects of acupuncture were evaluated by the hematoxylin and eosin staining (H&E), transmission electron microscopic (TEM) examination and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assays. The anti-inflammatory mechanism of acupuncture was studied by using the expressions of microRNA-146a (miR-146a) mediated nuclear factor-kappa B (NF-κB) signaling pathway-related proteins were detected by immunofluorescence, western blotting, quantitative real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA).

Results

Rats injected by D-galactose (D-gal) revealed apparent skeletal muscle atrophy with significantly reduced cross-sectional area and fiber diameter. In contrast, acupuncture treatment alleviated these hallmarks of skeletal muscle atrophy and mitigated the mitochondrial aberrations and skeletal muscle apoptosis in D-gal rats. In addition, acupuncture also downgraded the overexpression of inflammatory factors in skeletal muscle, influenced miR-146a and the target genes level, and inhibited NF-κB nuclear translation in D-gal rats.

Conclusions

Acupuncture may ameliorate skeletal muscle atrophy, and its effects may be associated with the control of mitochondrial function regulation and the suppression of inflammation.

Practitioners' perspectives on acupuncture treatment for postpartum depression: A qualitative study

BACKGROUND

Acupuncture may become a treatment for postpartum depression (PPD). Currently, little is known about the use of acupuncture in the treatment of PPD from the point of view of practitioners. The aim of this study was to explore practitioners' perspectives on the treatment of PPD with acupuncture and provide suggestions for future improvement.

METHODS

This study employed a qualitative descriptive method. Semistructured, open-ended interviews were conducted with 14 acupuncture practitioners from 7 hospitals via face-to-face or telephone interviews. The data were collected using interview outline from March to May 2022 and analysed using qualitative content analysis.

RESULTS

In general, the use of acupuncture for treating PPD was positively regarded by practitioners. They claimed that acupuncture is both safe and helpful for breastfeeding women who are experiencing emotional discomfort and that it can alleviate a variety of somatic symptoms. The following three themes were extracted: (a) patient acceptance and compliance; (b) acupuncture as a treatment for PPD; and (c) the advantages and drawbacks of acupuncture treatment.

CONCLUSION

Practitioners' optimistic outlooks demonstrated that acupuncture is a promising treatment option for PPD. However, the time cost was the most significant barrier to compliance. Future development will focus mostly on improving acupuncture equipment and the style of service.

[Acupuncture with an Aftermath]

Acupuncture with an Aftermath Abstract. A 70-year-old female patient presents with a 6-hour history of left sided thoracic pain and acutely exacerbated cough in the emergency department. Earlier in the morning she had undergone acupuncture therapy. The clinical examination revealed tachypnea with diminished breath sounds on the left side and hyperresonance to percussion. The laboratory findings revealed elevated D-Dimer and NT-proBNP. Due to the clinical presentation and the laboratory results, a CT scan of the chest was made, which confirmed the suspected left-side pneumothorax. The chest radiograph showed complete resolution of the pneumothorax within two days after chest tube placement.

Acupuncture-Associated Mycobacterium massiliense and Scedosporium Infections Superimposed by Tetanus

Background

Tetanus has rarely been reported in Thailand since 1982 due to 100% tetanus vaccination coverage during the neonatal period of life. However, the reemergence of tetanus has been observed in our country during the past decade, mainly due to the increasing number of migrants traveling from neighboring countries in search of work. Acupuncture has become an essential part of alternative and complementary medicine. To our knowledge, acupuncture-associated Mycobacterium abscessus and Scedosporium infections superimposed by tetanus have never been reported. Case Presentation. A 55-year-old Thai female with schizophrenia was hospitalized due to a 4-day course of trismus, dysphagia, and back muscle spasms. Upon admission, a clinical diagnosis of tetanus was made, which included muscle rigidity and reflex muscle spasms, despite a recent history of diphtheria-tetanus (dT) vaccination for tetanus prophylaxis after 2 episodes of falling complicated by two lacerations on the left shoulder and head. Endotracheal intubation for airway protection was given, in addition to tetanus immunoglobulin, metronidazole, and diazepam which were prescribed to the patient. Incision and drainage of the wound on the left shoulder yielded 40 mL of pus, which subsequently grew Clostridium species, Mycobacterium massiliense, and Scedosporium on anaerobic bacterial, mycobacterial, and fungal cultures, respectively. An incision of an acupuncture wound on the abdominal wall yielded 1 mL of pus, which exhibited positive acid-fast bacilli (AFB) on AFB stain. Mycobacterial culture finally grew M. massiliense. The organism was susceptible to amikacin and clarithromycin. Amikacin, clarithromycin, ciprofloxacin, and voriconazole were then added. The patient gradually improved and was discharged after one month of hospitalization. The patient was reported to be doing well, with no neurological sequelae, when last seen one month after discharge.

Conclusions

To our knowledge, this is the first case of acupuncture-associated M. massiliense and Scedosporium infections superimposed by tetanus. In Thailand, the occurrence of acupuncture by nonqualified individuals and the reemergence of tetanus remain prevalent. Hence, it is not uncommon to see tetanus in association with acupuncture-related nontuberculous mycobacterial/fungal infection.

Auricular Acupuncture for Preoperative Anxiety in Parturient Women with Scheduled Cesarean Section: A Randomized Placebo-Controlled Blind Study

Introduction: Preoperative anxiety before cesarean section is a major issue. Nonpharmacologic anxiety control is believed to be more suitable in pregnant women. Auricular acupuncture (AA) is an inexpensive, easy-to-use, and validated intervention to reduce anxiety in different surgical settings. We evaluated the effect of AA on preoperative cesarean section anxiety. Methods: In a prospective, blind, controlled trial, pregnant women with a scheduled cesarean section under spinal anesthesia were randomized to receive AA with needle, AA without needle (sham), or usual care (no intervention). Anxiety level was assessed by using a visual analogue scale for anxiety (VAS-A; 0-minimal anxiety, 100-maximal anxiety) at three time points: inclusion (pre-induction room-T0), when entering the operating room (T1), and before incision (T2). The primary outcome was the VAS-A variation (percentage changes) between T0 and T1 in the AAe group compared with that in the sham AA group. The secondary outcomes were the VAS-A variation between T0 and T1 in the AA group compared with that in the control group, and the variation between T0 and T2 compared between the three groups, the effect of AA on parasympathetic tone, and the incidence of adverse effects. Results: In women immediately before anesthesia for cesarean section, the AA produced a 19% decrease of anxiety, compared with a 21% anxiety increase in sham AA, which is significantly different. The effect of AA was more present in women with low initial anxiety. The proportion of patients reaching clinically significant anxiety reduction (>33% from the initial level) was 2.5 times higher in the AA group (p = 0.02) compared with the sham group. No differences in anxiety variations were found compared with the no-intervention group. No effect of AA was noted on parasympathetic tone. Conclusion: Compared with sham, AA decreased maternal anxiety level when arriving in the operation room and just before the beginning of the cesarean section, with a trend toward improvement compared with usual care.

Saam Acupuncture for Treating Functional Dyspepsia: A Feasibility Randomized Controlled Trial

Objective

Functional dyspepsia (FD) is a common gastrointestinal disorder that significantly affects sufferers' quality of life and increases the economic burden on society. Saam acupuncture, a form of traditional Korean acupuncture, is frequently used to treat FD in Korean medicine clinical settings. This study aimed to evaluate the feasibility and preliminary effectiveness and safety of Saam acupuncture for treating FD.

Methods

We conducted a pilot, pragmatic, assessor-blinded randomized controlled trial. Patients with FD according to the ROME III criteria were randomly allocated to an acupuncture plus usual care group or a usual care group. Saam acupuncture based on individualized FD and systemic symptoms was conducted in the acupuncture group three times per week for 4 weeks. Study feasibility outcomes, including recruitment, completion, and acupuncture adherence rates, were calculated. In addition, preliminary evaluation of participant responses to the intervention was tested using the gastrointestinal symptom (GIS), FD-related quality of life (FD-QoL), visual analog scale (VAS), patient global assessment (PGA), and EuroQol-5 Dimensions (EQ-5D) scores.

Results

Twenty-four participants who met the eligibility criteria were included. The recruitment and completion rates of the clinical trials were 60% and 79.2%, and the acupuncture adherence rate was 83.3%. Although there was no significant difference between the two groups in the dyspepsia symptoms as measured by GIS, VAS, and PGA at Week 4, significant differences were found between the two groups at the follow-up assessments (Weeks 8 and 12). In particular, the early satiety subscore of GIS was significantly improved in the Saam acupuncture group compared with the usual care group at Week 4. The quality of life measured by FD-QoL and EQ-5D improved only in the Saam acupuncture group, although there were no significant differences between the two groups. No adverse events related to Saam acupuncture were reported.

Conclusions

Saam acupuncture can be a feasible, preliminarily effective, and safe treatment for FD. Further confirmatory trials with a larger sample size are needed to confirm its effectiveness and safety. The trail is registered with CRIS-KCT0000164, URL: https://cris.nih.go.kr/cris/search/detailSearch.do/2098.

Efficacy of Acupuncture and Moxibustion in Alopecia: A Narrative Review

Acupuncture is the practice of applying needles to target specific pressures points in the body. Since originating in China, acupuncture has been practiced for thousands of years to treat numerous conditions including chronic pain and mood disorders. Alopecia is a common dermatologic condition associated with psychological distress and decreased quality of life. Although it remains underexplored in western medicine, recent evidence suggests that acupuncture may be efficacious in the treatment of alopecia. In this review, we discuss the available evidence describing the efficacy of acupuncture or moxibustion alone (ACU) and in combination with other traditional and alternative interventions (ACU + TRAD) for hair loss. Additionally, the proposed physiologic mechanisms, targeted acupuncture points, and the benefits and barriers to treatment will be further described. An exploratory search using PubMed, EMBASE and Scopus databases was performed for studies that evaluated the effect of acupuncture and moxibustion on alopecia. In these studies, both ACU and ACU + TRAD were efficacious for numerous etiologies of hair loss including alopecia areata, androgenetic alopecia, and seborrheic alopecia. Given their ability to modulate the immune system, as well as neuronal networks associated with emotional cognition, the most frequently targeted acupoints were ST 36, GV 20, and LR 3. The proposed mechanistic effect is dependent upon disease etiology and is theorized to be twofold: reduction of inflammation and decrease in testosterone levels. The limited side effect profile of acupuncture makes it an advantageous treatment option, however, factors including cost, time, limited access, and aversion to needles may serve as barriers to treatment.

Assessment of Completeness of Reporting in Randomized Controlled Trials of Acupuncture Therapy for Chronic Obstructive Pulmonary Disease

Objective

To assess the completeness of reporting in randomized controlled trials (RCTs) of acupuncture therapy (AT) for chronic obstructive pulmonary disease (COPD).

Methods

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chongqing VIP (CQVIP), WANFANG Data, and China Biology Medicine (CBM) for studies published from their inception to May 8, 2021. The completeness of reporting was evaluated by CONSORT statement and STRICTA guidelines. Univariate and multivariate regression analyses were performed to preliminarily explore the factors related to completeness of reporting.

Results

A total of 44 RCTs were included. The overall quality score (OQS) based on the CONSORT statement and STRICTA guidelines ranged from 3 to 26 and 7 to 14, with a median of 10 and 11, respectively. Among the 35 items of the CONSORT statement, 10 items were fully reported with reporting rate > 70%, and 11 items were poorly reported at a rate < 5%. Among the 17 items of the STRICTA guidelines, 10 items were adequately reported with > 70%, and only 3 items were incompletely reported at a rate < 20%. The agreement of most items was determined as “good”, “substantial”, or “moderate”. By regression analysis, publication language (β coefficient: 6.432, 95% CI: 3.202 to 9.663, P <0.001) and funding source (β coefficient: 3.159, 95% CI: 1.045 to 5.273, P =0.004) acted as independent predictors of completeness of reporting according to the CONSORT statement. However, no variables associated with the STRICTA guidelines were identified.

Conclusion

The completeness of reporting of AT for COPD was inadequate. The condition relatively improved for trials with publication in the English language and funding source. By recommendation, reports should be strictly standardized in accordance with the CONSORT statement and STRICTA guidelines to improve the clinical research evidence of AT for COPD.

Efficacy and Safety of Acupuncture and or Moxibustion for Managing Primary Dysmenorrhea: A Systematic Review and Meta-Analysis

Acupuncture and moxibustion have been accepted as add-on options for primary dysmenorrhea (PD); however, the clinical evidence is still inadequate. We searched AMED, CENTRAL, EMBASE, PubMed, Web of Science, CBM, CNKI, VIP, Wangfang database, ANZCTR, ClinicalTrials.gov, and the WHO ICTRP, from their inception to February 2021. The pooled analysis of 13 RCTs with 675 participants for VAS showed that acupuncture and moxibustion were more effective in managing PD than the control group with the MD of -1.93 (95% CI [-2.80, -1.06] and -2.67 (95% CI [-4.96, -0.38]). With the CMSS, seven studies with 487 participants showed that these modalities were more effective than the control group with the MD of -7.58 (95% CI [-10.97, -4.19]) and -3.78 (95% CI [-6.90, -0.66]). The findings indicated that acupuncture and moxibustion could relieve pain effectively and has fewer adverse events (AEs) in managing PD.

Patient Attitudes Toward Acupuncture in the Perioperative Setting

Introduction: Acupuncture is a potential treatment option for pain, nausea, vomiting, anxiety, and agitation in the perioperative period. Patient preference for participating in acupuncture in the perioperative period is not well understood. The aim of this study was to quantify patient interest in perioperative acupuncture, explore the relationship between acupuncture interest, insurance coverage and patient cost, and identify clinical factors associated with patient interest in acupuncture. Materials and Methods: Adult patients evaluated in the Preoperative Evaluation Clinic at the Mayo Clinic in Phoenix, AZ, between June 2019 and July 2019, received a voluntary survey to assess their attitudes toward receiving acupuncture in the perioperative period. Patient interest in acupuncture to help treat pain, anxiety, and postoperative nausea and vomiting, as well as their willingness to pay for such services, were assessed. Demographic data, American Society of Anesthesiologists (ASA) physical class, scheduled procedure, and insurance coverage were extracted from the medical record. Univariate analysis was performed to estimate interest in acupuncture. Results: Three hundred and seven respondents were included in this study with a response rate of 60.4%. A total of 68.4% of study participants were interested in receiving perioperative acupuncture. Of those interested in acupuncture, 86.7% were interested if acupuncture was offered at no cost (either free or fully covered by insurance). A total of 47.1% of those patients interested in acupuncture would be interested if the cost of acupuncture was between 20 and 50 U.S. dollars. A total of 8.6% would be interested in acupuncture if patients were expected to pay the full cost of treatment (estimated 175 U.S. dollars). Age, sex, ASA status, type of surgery, risk of procedure, and Medicare/Medicaid coverage were not statistically associated with interest in acupuncture. Conclusions: When there is little to no direct cost to the patient, the majority of patients are interested in acupuncture in the perioperative period.

Patients' perceptions on non-specific effects of acupuncture: Qualitative comparison between responders and non-responders

BACKGROUND

Non-specific effect of acupuncture constitutes part of the overall effect generated via clinical encounter beyond needle insertion and stimulation. It is unclear how responders and non-responders of acupuncture experience non-specific effects differently. We aimed to compare their experiences in a nested qualitative study embedded in an acupuncture randomized trial on functional dyspepsia.

METHODS

Purposive sampling was used to capture experience of responders (n=15) and non-responders (n=15) to acupuncture via individual in-depth interviews. Design and analysis followed a framework analysis approach, with reference to an existing model on acupuncture non-specific effects. Themes emerging outside of this model were purposefully explored.

RESULTS

Responders had a more trusting relationship with acupuncturist in response to their expression of empathy. In turn they were more actively engaged in lifestyle modifications and dietary advice offered by acupuncturists. Non-responders were not satisfied with the level of reassurance regarding acupuncture safety. They were also expecting more peer support from fellow participants, regarded that as an empowerment process for initiating and sustaining lifestyle changes.

CONCLUSIONS

Our results highlighted key differences in acupuncture non-specific effect components experienced by responders and non-responders. Positive non-specific effects contributing to overall benefits could be enhanced by emphasizing on empathy expression from acupuncturists, trust-building, offering appropriate explanations on safety, and organizing patient support groups. Further research on the relative importance of each component is warranted.

The Effect of Acupuncture on Hand and Wrist Pain Intensity, Functional Status, and Quality of Life in Adults: A Systematic Review

Objective: This systematic review examined the effects of acupuncture on hand-and-wrist pain intensity, functional status, quality of life, and incidence of adverse effects in adults. Methods: Searches of 6 databases and previous reviews for randomized controlled trials (RCTs) were performed. Each outcome was analyzed for participant conditions, interventions, controls, and follow-up times determined a priori. Active controls were excluded. Follow-up periods were based on Cochrane 5.1.0 guidelines. The results were tabulated and described narratively. Results: In the 10 included RCTs (622 participants), 6 had a low risk of bias. For cryotherapy-induced pain, 1 trial showed significant pain reduction post treatment. For rheumatoid arthritis, 1 trial shown significant pain reduction and function improvements post treatment and short-term. For carpal tunnel syndrome, 1 trial showed significant pain reduction and functional improvements intermediate-term, while 3 trials suggested no significant difference. For tenosynovitis, 1 trial showed significant pain reduction and function improvements short-term. For poststroke impairments, 1 trial showed significant function improvements post treatment and at short-term, while another trial suggested no significant difference. No significant improvements were noted for trapezio-metacarpal joint osteoarthritis. In 2 trials, adverse effects occurred in patients with carpal tunnel syndrome; yet acupuncture appeared to be relatively safe. Conclusions: Acupuncture may be effective and safe for short-term pain reduction and functional improvement in hand-and-wrist conditions. Clinicians should interpret the results with caution due to small sample sizes and clinical heterogeneity. Future research is warranted.

Low methodological quality of systematic reviews on acupuncture: a cross-sectional study

BACKGROUND

While well-conducted systematic reviews (SRs) can provide the best evidence on the potential effectiveness of acupuncture, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study aimed to evaluate the methodological quality of a representative sample of SRs on acupuncture effectiveness.

METHODS

Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on the treatment effect of manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs must contain at least one meta-analysis and be published in English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the studies with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman's rank correlation coefficients.

RESULTS

A total of 106 SRs were appraised. Only one (0.9%) SR was of high overall methodological quality, zero (0%) was of moderate-quality, six (5.7%) and 99 (93.4%) were of low-quality and critically low-quality respectively. Among appraised SRs, only ten (9.4%) provided an a priori protocol, four (3.8%) conducted a comprehensive literature search, five (4.7%) provided a list of excluded studies, and six (5.7%) performed meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality.

CONCLUSIONS

Methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats.

Traditional Chinese Medicine for Postoperative Care following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis

Objectives

This review verifies the clinical effects of traditional Chinese medicine (TCM) combined with conventional rehabilitation after anterior cruciate ligament reconstruction (ACLR).

Methods

MEDLINE/PubMed, EMBASE, CENTRAL, JMAS, CNKI, and seven Korean databases were searched using predetermined strategies. The risk of bias was assessed using Cochrane Collaboration's tool and a meta-analysis was conducted accordingly.

Results

Nineteen randomized controlled trials involving 1283 participants were included in this systematic review and meta-analysis. The TCM treatment group showed more significant improvements in pain (MD −0.74, 95% CI [−0.93, −0.54]; I2 = 89%), range of motion (ROM) (SMD 1.19, 95% CI [0.78, 1.59]; I2 = 78%), and knee swelling (SMD −1.72, 95% CI [−2.38, −1.07]; I2 = 76%). The Lysholm score of the TCM treatment group significantly improved (MD 5.62, 95% CI [3.93, 7.32]; I2 = 84%) relative to the control group. The IKDC subjective score (MD 3.40, 95% CI [−0.61, 7.41]; I2 = 97%) and the hospital for special surgery (HSS) score did not improve initially (MD 6.79, 95% CI [−1.27, 14.86]; I2 = 97%) but did so during the subgroup analysis. TCM showed a long-term effect on the IKDC subjective score (MD −0.51, 95% CI [−1.69, 0.67]; I2 = 30%). A longer treatment period of 12 weeks showed more improvement (MD 5.96, 95% CI [0.69, 11.22]; I2 95%).

Conclusion

TCM can be used as an adjuvant therapy to conventional rehabilitation for relieving pain, improving ROM and oedema, and facilitating better function of the knee joint after ACLR. However, this recommendation should be cautiously applied in clinical practice owing to the low quality of the included studies.

Opioid-Induced Constipation and Acupuncture: A Case Discussion

BACKGROUND

Use of acupuncture for treatment of functional constipation is well studied; however, studies examining use of acupuncture for opioid-induced constipation are limited.

CASE DESCRIPTION

A 70-year-old woman with newly diagnosed multiple myeloma discovered after presentation to the emergency room with severe back pain. Pain management required use of opioids, escalating to effect. Hospital course was complicated by opioid-induced constipation causing abdominal pain, nausea, and ileus despite aggressive titration of stimulant and osmotic laxatives as well as administration of suppositories and enemas on multiple occasions. Prior to nasogastric tube placement for the ileus, the patient requested acupuncture treatment in attempt to relieve constipation. Shortly after acupuncture session, patient passed multiple stools with improvement in abdominal pain and nausea and avoidance of nasogastric tube.

CONCLUSION

Acupuncture for opioid-induced constipation may provide symptom relief through use of nonpharmacologic interventions; however, further studies are needed to determine the optimal therapeutic approach.

Acupuncture-related adverse events: systematic review and meta-analyses of prospective clinical studies

OBJECTIVE

Overview on risks of acupuncture-related adverse events (AEs).

DESIGN

Systematic review and meta-analyses of prospective studies.

DATA SOURCES

PubMed, Scopus and Embase from inception date to 15 September 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Prospective studies assessing AEs caused by needle acupuncture in humans as primary outcome published in English or German.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers selected articles, extracted the data and assessed study quality. Overall risks and risks for different AE categories were obtained from random effects meta-analyses.

MAIN OUTCOMES

Overall risk of minor AEs and serious adverse events (SAEs) per patients and per treatments.

RESULTS

A total of 7679 publications were identified. Twenty-two articles reporting on 21 studies were included. Meta-analyses suggest at least one AE occurring in 9.31% (95% CI 5.10% to 14.62%, 11 studies) of patients undergoing an acupuncture series and in 7.57% (95% CI 1.43% to 17.95%, 5 studies) of treatments. Summary risk estimates for SAEs were 1.01 (95% CI 0.23 to 2.33, 11 studies) per 10 000 patients and 7.98 (95% CI 1.39 to 20.00, 14 studies) per one million treatments, for AEs requiring treatment 1.14 (95% CI 0.00 to 7.37, 8 studies) per 1000 patients. Heterogeneity was substantial (I2 >80%). On average, 9.4 AEs occurred in 100 treatments. Half of the AEs were bleeding, pain or flare at the needle site that are argued to represent intended acupuncture reaction. AE definitions and assessments varied largely.

CONCLUSION

Acupuncture can be considered among the safer treatments in medicine. SAEs are rare, and the most common minor AEs are very mild. AEs requiring medical management are uncommon but necessitate medical competence to assure patient safety. Clinical and methodological heterogeneity call for standardised AE assessments tools, clear criteria for differentiating acupuncture-related AEs from therapeutically desired reactions, and identification of patient-related risk factors for AEs.

PROSPERO REGISTRATION NUMBER

CRD42020151930.

Complementary and Alternative Medicine Therapies for Irritable Bowel Syndrome

Complementary and alternative medicine (CAM) is a term used to define a broad range of therapies, most commonly grouped into natural products, mind-body medicine, and traditional systems of medicine. Patients with irritable bowel syndrome (IBS) commonly use CAM therapies, although there are many barriers that may keep patients and providers from talking about a patient's CAM use. Despite limited quantity and quality of evidence of CAM for IBS, providers can better counsel patients on CAM use by understanding pitfalls related to CAM use and by learning what is known about CAM.

Acupuncture for Behavioral and Psychological Symptoms of Dementia: A Systematic Review and Meta-Analysis

Dementia is an important health issue worldwide, and non-pharmacological strategies for the management of behavioral and psychological symptoms of dementia (BPSD) are considered to be important. This review analyzes the effectiveness and safety of acupuncture for BPSD. Thirteen electronic databases were comprehensively searched to find clinical studies using acupuncture on BPSD, published up to December 2020. Five randomized controlled clinical trials and two before-after studies, mainly on Alzheimer’s disease (AD), were included. Meta-analysis suggested that the total effective rate based on BPSD symptoms in the acupuncture combined with psychotropic drugs group was significantly higher than that in the psychotropic drugs group (risk ratio, 1.27; 95% confidence interval, 1.11 to 1.45; I² = 51%). In terms of other outcomes related to BPSD, acupuncture as an adjunctive therapy, but not as monotherapy, was associated with significant benefits in most included studies. However, the included studies did not have optimal methodological quality. Our review highlights the limited evidence proving the effectiveness and safety of acupuncture for BPSD in patients with AD. Although some clinical studies have reported the potential benefits of adjuvant acupuncture in managing BPSD, the evidence is not robust and is based on small studies. Therefore, high-quality research in this field is needed.

The Effectiveness of Laser Acupuncture for Treatment of Musculoskeletal Pain: A Meta-Analysis of Randomized Controlled Studies

Objective

To evaluate the treatment effectiveness of laser acupuncture (LA) in patients with musculoskeletal pain.

Methods

Major electronic databases, including Medline, PubMed, Embase, Cochrane Library, CINAHL, and Scopus were searched to identify double-blind, randomized controlled trials of LA in musculoskeletal disorders. The primary outcome was the treatment efficacy for pain. The secondary outcomes included the comparison of disability, functional impairment, and dropout rate between LA and sham treatment, as well as the effect of sham treatment for pain. The results from included studies were synthesized with the random effects model.

Results

In total, 20 articles comprising 568 patients receiving LA and 534 patients receiving sham treatment were included in the current study. Our analysis showed LA significantly reduced pain (g=0.88, 95% confidence interval [CI]=0.35 to 1.42, p=0.001), disability (g=0.68, 95% CI=0.29 to 1.08, p<0.001), and functional impairment (g=0.67, 95% CI=0.32 to 1.03, p<0.001). Through meta-regression analysis, we found these effects were not moderated by mean age, the percentage of females, or treatment duration. Additionally, there was no significant difference between the two groups in dropout rate (risk ratio=0.73, p=0.08), and the sham treatment significantly reduced only pain intensity (g=0.54, 95% CI=0.32 to 0.77, p<0.001).

Conclusion

Our findings supported that LA significantly reduced pain, disability, and functional impairment in patients with musculoskeletal disorders. Further researches are required to determine the optimal therapeutic parameters and the suitable patients for receiving LA.

Protocol Registration

CRD42020190919.

Risks and Safety of Extended Auricular Therapy: A Review of Reviews and Case Reports of Adverse Events

OBJECTIVE

Auricular acupuncture (AA) and extended auricular therapy (AT) are a part of acupuncture practice shown to benefit patients with pain, anxiety, and other conditions, with cost-effective access enhanced when given in a group setting. Yet there are safety concerns and risks, perhaps unnecessary risks, that attend embedded, indwelling needles applied to the ear as a means of extended AT.

METHODS

Electronic searches were conducted in PubMed, MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) for "auriculotherapy," "auricular acupuncture" or "auricular acupressure," "safety," "adverse events," "chondritis," and "perichondritis," with additional manual review of titles, links, and reference lists. Individual auricular therapy adverse event (AE) case reports were included, as well as systematic reviews and or meta-analyses if they evaluated AEs associated with AT.

RESULTS

Nineteen auricular AE case reports and nine safety reviews of or including auriculotherapy were included. Ten systematic reviews of AT with eight specific reviews of auricular acupressure (AP) were also included.

CONCLUSIONS

The primary AE risks is infection, perichondritis, and chondritis stemming from embedded or indwelling needles or potential inadvertent needlesticks from contaminated roaming sharps. Extended AP i.e., application of spheres, preferably seeds (natural, nontoxic botanical Vaccaria seeds) provides clinical benefit without the risks associated with embedded needles. More research is needed to establish if embedded needles at the ear are even necessary or have any advantage over in-session auricular acupuncture for immediate pain relief followed by ear acupressure.

Pneumothorax Following Acupuncture

Pneumothorax, the accumulation of air between the visceral and parietal pleurae, represents a potentially serious cause of chest pain in patients presenting to the emergency department. While there are known risk factors for spontaneous pneumothorax, in rare cases dry needling and acupuncture, forms of complementary and alternative medicine, have been known to result in pneumothorax.

We present a case of a 38-year-old healthy female who presented with acute onset of pleuritic chest pain to the Emergency Department. On further history, it was discovered that she had received dry needling acupuncture for unrelated back pain the day prior to presentation. She was initially investigated with an electrocardiogram (ECG), which was unremarkable, and point of care ultrasound (POCUS), which showed absent lung sliding and the presence of a lung point on the right side, indicative of pneumothorax. This case describes the key features of pneumothorax on POCUS and how POCUS can be a valuable tool in the diagnosis of lung pathologies and highlights the importance of considering the rare but potentially serious complications of complementary and alternative medicine practices which are typically regarded as safe.

Application of traditional Chinese therapy in sports medicine

Chinese herbs have been used as dietary supplements to improve exercise performance. However, evidence-based studies for the use of Chinese herbs in sports remain scarce. Traditional Chinese therapy (TCT), a form of traditional Chinese non-pharmacological intervention, has remained in use for thousands of years in sports medicine. TCT is beneficial for sports injuries and in enhancing skill development, and is becoming increasingly popular among athletes, fitness enthusiasts, and individuals who regularly exercise. The therapeutic effects of TCT have been demonstrated by clinical and experimental studies, but using these modalities still is associate with potentially adverse effects. Further well-designed studies are necessary to confirm the efficacy of TCT in sports medicine. This review aims to summarize the application of TCT, discuss the issues surrounding TCT clinical research, and provide suggestions for applying traditional Chinese methods in the field of sports medicine.

Traditional and complementary medicine for promoting healthy ageing in WHO Western Pacific Region: Policy implications from utilization patterns and current evidence

BACKGROUND

With increasing burden of chronic non-communicable diseases (NCD), ageing becomes a global public health concern, and the World Health Organization Western Pacific Region has no exception. To address the NCD challenge, priority should be given to promote healthy ageing across the life-course. As traditional and complementary medicine (T&CM) is popular within the Region, it is of policy interest to explore possibilities of applying T&CM for promoting healthy ageing.

METHODS

We first summarized sources of clinical evidence supporting the use of T&CM. We then searched publications through MEDLINE from its inception to April 2020 to identify studies focusing on the perception of T&CM among older people. Finally, taking current evidence base and patient choice into account, we generated policy recommendations for of integrating T&CM into health systems.

RESULT

Experiences from countries with different income levels suggested that promoting evidence-based T&CM as self-care modalities would be the most efficient way of maximizing impact among the older population, especially via a train the trainer approach. Meanwhile, popularity of natural products in the Region mandates policy makers to implement appropriate regulation and quality assurance, and to establish pharmacovigilance to detect potential harm. The role of pharmacists in advising patients on self-medication using natural products needs to be strengthened.

CONCLUSION

Policy-makers will benefit from continued global dialogue and sharing of experience in T&CM policy development and implementation. Harmonizing regulatory frameworks for natural products at regional and global levels, including mutual recognition of regulatory approval, to improve standards and protect patients could be a priority.

Trends and Patterns in Traditional Chinese Medicine Use Among Chinese Population in Late Adulthood: An Eight-Year Repeated Panel Survey

Traditional Chinese medicine (TCM), originated from China, is different from Western medicine in theory and practice. This study aimed to document the longitudinal trends and the patterns by demographical characteristics in the prevalence of TCM among the middle-aged and elderly Chinese population. This study used nationally representative longitudinal survey data from the China Health and Retirement Longitudinal Study (CHARLS), covering approximately 20,000 individuals in each panel survey from 2011 to 2018. The questions regarding medication use in the questionnaire was used to identify the TCM users. The prevalence of using TCM for treating chronic diseases among the patients with chronic diseases stabilized between 2011 and 2018, while the prevalence of TCM use for any purpose among the overall population climbed from 19.03% (95% CI 18.37% to 19.69%) in 2011 to 23.91% (95% CI 23.23% to 24.60%) in 2015. Moreover, the prevalence of TCM use for nonchronic conditions among the overall population increased during the same period as well. The TCM users were more likely to be females and city dwellers. The increasing prevalence of TCM use for any purpose among the overall population reflects the increasing influence and potentials of TCM by year. With the expected rising demand in TCM for the following decades in China, more clinical trials on safety and healthcare policy regarding TCM are merited in the future.

Effectiveness of acupuncture for the recovery of gastrointestinal function of patients with gastric cancer in the postoperative period: A protocol for systematic review and meta-analysis

BACKGROUND

Gastric cancer (GC) is the most common malignant tumors in the world and surgical resection remains the primary treatment for it. Postoperative patients often suffer from gastrointestinal dysfunction as the most common side effects of surgery for GC patients. Acupuncture has a regulatory effect on gastrointestinal function. We conducted this study to assess the effectiveness of acupuncture on the restoration of gastrointestinal function of postoperative patients with GC.

METHODS

Seven electronic databases will be searched from inception to November 2020 to identify any relevant study: Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), and Chinese Scientific Journal Database (VIP database). No restriction on time and language. The primary outcome measure will be the Time to First Flatus and secondary outcome measures include the time of first defecation and the quality of life (QOL) and the number of patients with abdominal distention. We will use EndNote V.9.1 to screen the eligible literature and the I2 statistic to assess heterogeneity in the included studies. The meta-analysis will be conducted using the Review Manager (RevMan) software (V.5.3).

RESULTS

Our study aims to systematically assess whether the pooled effects of currently available trials prove effects of acupuncture in improving gastrointestinal function of patients with GC in the postoperative period.

CONCLUSION

This study will conduct an evaluation about the efficacy of acupuncture for the recovery of gastrointestinal function of patients with GC in the postoperative period, making up for the lack of relevant clinical evidence.

INPLASY REGISTRATION NUMBER

INPLASY2020110066.

Prevenção quaternária e práticas integrativas e complementares em saúde (I)

Introdução: A medicina família e comunitária (MFC) vem desenvolvendo a prevenção quaternária (P4) com uma centralidade no uso crítico de recursos biomédicos. Em paralelo, vem crescendo a grande procura e o uso das práticas integrativas e complemantares em saúde (PICS) por pessoas e profissionais de saúde, com crescentes investigação científica e institucionalização das PICS, sobretudo na atenção primária à saúde (APS). Objetivo: Descrever contribuições potenciais de várias PICS para a prática da P4. Métodos: Ensaio baseado em literatura selecionada assistematicamente, em perspectiva hermenêutica de compreender a interface P4-PICS e descrever sinteticamente contribuições possíveis de PICS para a prática da P4. Resultados e Discussão: O uso de PICS como P4 pode facilitar o autoconhecimento e a crítica dos profissionais; reduzir a medicalização, se assim direcionadas; enriquecer o autocuidado; reduzir a iatrogenia dos cuidados e pluralizar a terapêutica; transformar a observação assistida em terapêutica; otimizar a singularização da abordagem; amplificar/diversificar os estímulos à autocura e fornecer novos entendimentos e vias de acesso à saúde-doença. Conclusão: São amplas e férteis as possibilidades de uso de PICS como P4 na MFC e na APS, tanto na prevenção como no cuidado clínico aos adoecidos.

Evaluation of an effectiveness and safety of the electroacupuncture in the management of intractable neuropathic pain: A prospective, open-labeled, randomized, cross-over clinical trial

BACKGROUND

There is no sufficient evidence on the effectiveness of acupuncture for neuropathic pain. This protocol describes a study that aims to evaluate the effectiveness and safety of electroacupuncture combined with conventional medicine for patients with intractable neuropathic pain, when compared with conventional medicine alone.

METHODS/DESIGN

This study is a prospective, open-labeled, randomized, cross-over clinical trial. A total of 40 patients with neuropathic pain who had a numeric rating scale (NRS) score of over 4 despite receiving conventional treatment for more than 3 months will be enrolled. Participants will receive conventional treatment for neuropathic pain (treatment C) or treatment C combined with 12 additional sessions of electroacupuncture treatment (treatment A) for 6 weeks. Participants will be randomly assigned to 1 of the 2 sequence groups (AC and CA group) with a 1:1 allocation. The differences of responder in the composite efficacy outcomes, which consist of the NRS, Brief Pain Inventory-Short Form (BPI-SF) pain subscale, and global assessment at 6 weeks after randomization will be examined as the primary outcome. Secondary outcomes include differences in the NRS, the Short-Form McGill Pain Questionnaire, BPI-SF, Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Medical Outcomes Study Sleep Scale, global assessment, EQ-5D, and incremental cost-effective ratio at 6 and 15 weeks after randomization. Adverse events, vital signs, and physical examinations will be recorded to evaluate safety.

DISCUSSION

The study protocol for this trial will provide up-to-date evidence on the effectiveness and safety of electroacupuncture for patients with intractable neuropathic pain. The results will be disseminated through a peer-reviewed journal and conference presentations.

TRIAL REGISTRATION

Clinical Research Information Service, ID: KCT0003615. Registered on March 12, 2019. https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=13410& ltype=&rtype=.

Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis

Question

Is the use of acupuncture and acupressure associated with improved cancer pain management compared with sham intervention and/or analgesic therapy alone?

Findings

In this systematic review of 17 randomized clinical trials and meta-analysis of 14 trials in the current English-language and Chinese-language literature, a significant association was found between real (compared with sham) acupuncture and reduced pain, and acupuncture combined with analgesic therapy was associated with decreased analgesic use. However, heterogeneity lowered the level of certainty of the evidence.

Meaning

This study found a moderate level of evidence that acupuncture and/or acupressure was significantly associated with lower pain intensity in patients with cancer compared with a sham control, which suggests a potential for a combination of acupuncture and acupressure to help reduce opioid doses in patients with cancer.

Importance

Research into acupuncture and acupressure and their application for cancer pain has been growing, but the findings have been inconsistent.

Objective

To evaluate the existing randomized clinical trials (RCTs) for evidence of the association of acupuncture and acupressure with reduction in cancer pain.

Data Sources

Three English-language databases (PubMed, Embase, and CINAHL) and 4 Chinese-language biomedical databases (Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals, China National Knowledge Infrastructure, and Wanfang) were searched for RCTs published from database inception through March 31, 2019.

Study Selection

Randomized clinical trials that compared acupuncture and acupressure with a sham control, analgesic therapy, or usual care for managing cancer pain were included.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. Random-effects modeling was used to calculate the effect sizes of included RCTs. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The primary outcome was pain intensity measured by the Brief Pain Inventory, Numerical Rating Scale, Visual Analog Scale, or Verbal Rating Scale.

Results

A total of 17 RCTs (with 1111 patients) were included in the systematic review, and data from 14 RCTs (with 920 patients) were used in the meta-analysis. Seven sham-controlled RCTs (35%) were notable for their high quality, being judged to have a low risk of bias for all of their domains, and showed that real (compared with sham) acupuncture was associated with reduced pain intensity (mean difference [MD], −1.38 points; 95% CI, −2.13 to −0.64 points; I² = 81%). A favorable association was also seen when acupuncture and acupressure were combined with analgesic therapy in 6 RCTs for reducing pain intensity (MD, −1.44 points; 95% CI, −1.98 to −0.89; I² = 92%) and in 2 RCTs for reducing opioid dose (MD, −30.00 mg morphine equivalent daily dose; 95% CI, −37.5 mg to −22.5 mg). The evidence grade was moderate because of the substantial heterogeneity among studies.

Conclusions and Relevance

This systematic review and meta-analysis found that acupuncture and/or acupressure was significantly associated with reduced cancer pain and decreased use of analgesics, although the evidence level was moderate. This finding suggests that more rigorous trials are needed to identify the association of acupuncture and acupressure with specific types of cancer pain and to integrate such evidence into clinical care to reduce opioid use.

Mechanisms Underlying the Antidepressant Effect of Acupuncture via the CaMK Signaling Pathway

The CaMK pathway has been proven to play an important role in regulating cognitive function and emotional response. Acupuncture through the CaMK pathway improves depression-like behavior and the molecular mechanism related to its antidepressant remains to be explored. In this study, we aimed to determine whether the ability of acupuncture at Baihui (GV20) and Shenting (GV24) points to treat depression is related to the regulation of key proteins in the CaMK pathway. A rat model of depression was induced by chronic unpredicted mild stress (CUMS). Model rats in the electroacupuncture group were subjected to acupuncture at the Baihui (GV20) and Shenting (GV24) acupoints once a day for 20 min. Model rats in the fluoxetine group were gavaged with fluoxetine (1.8 mg/kg). Immunohistochemistry and Western blotting assays were used to evaluate immunoreactivity for and the protein expression levels of CaMKII, CaMKIV, and CaM. The results showed that electroacupuncture had a significant effect in rats with depression. Electroacupuncture and fluoxetine regulated the expression of key proteins in the CaMK signaling pathway, which is related to depression, in the hippocampi of rats. This indicates that acupuncture at Baihui (GV20) and Shenting (GV24) may alleviate depressive symptoms and reduce work- and life-related burdens and stress by regulating the CaMK signaling pathway.

The Electric Shock during Acupuncture: A Normal Needling Sensation or a Warning Sign

The electric shock has been proposed as one of the new needling sensations in recent years. In acupuncture sensation scales, the electric shock is included by ASS and SNQS, but not SASS, MASS, and C-MMASS. Some scholars argue that the electric shock is a normal needling sensation, but some researchers do not agree with this view. This problem has not been resolved due to a lack of evidence from basic research. Literature and research point out that the electric shock is caused by inserting a needle into the nerve directly. A question of considerable scientific and practical interest is whether the electric shock should be a normal needling sensation. In this article, we review the historical documentation of the needling sensation and the process of formulating and improving acupuncture sensation scales to suggest that the electric shock may not be a normal needling sensation. Secondly, we collected and analyzed cases of nerve injury caused by acupuncture accompanied by the electric shock and why acupuncture caused the electric shock without nerve injury. It suggests that there may be a correlation between the electric shock and peripheral nerve injury, and acupuncture manipulation is an essential factor in adverse acupuncture events. Finally, we put forward that the electric shock during acupuncture is a warning sign that the peripheral nerve may be injured, rather than a normal needling sensation. In the future, we hope to have experimental studies on the mechanism of the electric shock or observational studies on the correlation between the electric shock and peripheral nerve injury to verify.